Protocol for a program of research from the Aging, Community and Health Research Unit: Promoting optimal aging at home for older adults with multimorbidity

Abstract Background: The goal of the Aging, Community and Health Research Unit (ACHRU) is to promote optimal aging at home for older adults with multimorbidity (2 chronic conditions) and to support their family/friend caregivers. This protocol paper reports the rationale and plan for this patient-oriented, cross-jurisdictional research program. Objectives: The objectives of the ACHRU research program are (i) to codesign integrated and person-centered interventions with older adults, family/friend caregivers, and providers; (ii) to examine the feasibility of newly designed interventions; (iii) to determine the intervention effectiveness on Triple Aim outcomes: health, patient/caregiver experience, and cost; (iv) to examine intervention context and implementation barriers and facilitators; (v) to use diverse integrated knowledge translation (IKT) strategies to engage knowledge users to support scalability and sustainability of effective interventions; and (vi) to build patient-oriented research capacity. Design: The research program was informed by the Knowledge-toAction Framework and the Complexity Model. Six individual studies were conceptualized as integrated pieces of work. The results of the three initial descriptive studies will inform and be followed by three pragmatic randomized controlled trials. IKT and capacity building activities will be embedded in all six studies and tailored to the unique focus of each study. Conclusions: This research program will inform the development of effective and scalable person-centered interventions that are sustainable through interagency and intersectoral partnerships with community-based agencies, policy makers, and other health and social service agencies. Implementation of these interventions has the potential to transform health-care services and systems and improve the quality of life for older adults with multimorbidity and their caregivers. Trial registration: NCT (study 4), NCT (study 5), and NCT (study 6). Keywords Older adults, multimorbidity, health interventions, pragmatic randomized controlled trial, home and community care 1 School of Nursing, McMaster University, Hamilton, Ontario, Canada 2Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada 3Aging, Community and Health Research Unit, McMaster University, Hamilton, Ontario, Canada 4McMaster Institute for Research on Aging, McMaster University, Hamilton, Ontario, Canada 5Department of Health, Aging and Society, McMaster University, Hamilton, Ontario, Canada 6 Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada 7Department of Family Medicine, University of Alberta, Edmonton, Alberta, Canada 8Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada 9 Program for Interprofessional Practice, Education and Research, McMaster University, Hamilton, Ontario, Canada 10 School of Geography and Earth Sciences, McMaster University, Hamilton, Ontario, Canada Corresponding author: Maureen Markle-Reid, School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada. Email: Journal of Comorbidity Volume 8: 1–16 ª The Author(s) 2018 DOI: 10.1177/2235042X Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License ( use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages ( Background As the population ages and life expectancy increases, our health-care system is increasingly challenged to address the complex care needs of older adults with multimorbidity (2 chronic conditions).1 By 2030, older adults will comprise 23% of the Canadian population. One in three (33%) Canadian older adults have multimorbidity, and account for 40% of health-care use.2 Older adults with multimorbidity report poorer health-related quality of life (HRQoL), higher use of health services and costs, and are at higher risk for adverse events (e.g. hospitalization and falls) and depression compared to those with a single condition. These older adults use a patchwork of costly services and programs that fail to meet their unique needs.3 Health service use in this population is largely driven by the number of chronic conditions they have, not their age.2 But, the number of chronic conditions alone does not reflect the complex care needs of older adults with multimorbidity. Instead, it is the context of people’s lives that determines their health. Thus, a person-centered approach is required for this population. Person-centered care, or “the right care for the right person at the right time,”4 must be informed not only by the collection of diseases, but also by the complex interaction between individuals’ social, cultural, ethnic, economic, geographical, gender and sex needs, health goals, and priorities. The challenge in achieving person-centered care is, in part, due to the persistent focus on the delivery of acute and episodic care for single diseases, making it difficult to be person-centered for the growing number of older adults with multimorbidity.5 It is well established that chronic illness is not just about the disease but intersects with the broader social determinants of health. An estimated 75% of the factors that influence health and health outcomes lie outside the health-care system,6 but a reactive approach focused on management of chronic diseases using a biomedical lens continues to have a strong foothold in health care.5 For the past decade, transformation of the health-care system across Canada has focused on strategies to provide a wider range of services to the growing population of older adults with multimorbidity within the context of cost containment.7 Most (92%) Canadian older adults live at home in the community; aging at home optimizes older adults’ health, independence, sense of well-being, and social connectedness.8 Home and community-based services have emerged as a viable and cost-effective solution to delivering a broad range of acute, chronic, rehabilitative, longterm, and palliative care services.9 Technological advances have enabled the delivery of increasingly complex, specialized care in the home, with most Canadians preferring to receive care in the comfort and familiarity of this setting compared to institutional settings. The result is increasing pressure on home and community-based services to provide accessible, person-centered interventions that support quality of life goals of older adults with multimorbidity, so they may continue to age at hom